A Dissertation on

A COMPARATIVE STUDY OF LICHTENSTEIN MESH REPAIR

VS NONMESH TISSUE REPAIR DESARDA’S TECHNIQUE

FOR INGUINAL HERNIA REPAIR

submitted to

THE TAMILNADU DR.MGR MEDICAL UNIVERSITY,

CHENNAI

with fulfillment of the regulations for the award of

M.S DEGREE IN GENERAL SURGERY

BRANCH I

GOVERNMENT KILPAUK MEDICAL COLLEGE,

CHENNAI

MAY – 2018

BONAFIDE CERTIFICATE

This is to certify that the dissertation entitled “A COMPARATIVE

STUDY OF LICHTENSTEIN MESH REPAIR VS NONMESH TISSUE

REPAIR DESARDA’S TECHNIQUE FOR INGUINALHERNIA REPAIR”

is a bonafide work of Dr. K.RASU submitted to The Tamilnadu Dr. M.G.R

Medical University in partial fulfilment of requirements for the award of the

degree of M.S. BRANCH I (GENERAL SURGERY) examination to be held in

MAY, 2018.

Prof. P.S.SHANTHI M.S DGO. Prof. R. KANNAN M.S.,

Professor of General Surgery H.O.D, Dept. of General Surgery

Govt. Kilpauk Medical College, Govt. Kilpauk Medical College,

Chennai – 600 010. Chennai – 600 010.

Prof. P.VASANTHAMANI, MD., DGO., MNAMS., DCPSY., MBA.

DEAN

Government Kilpauk Medical College & Hospital

Chennai – 600 010

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation titled “A COMPARATIVE STUDY

OF LICHTENSTEIN MESH REPAIR VS NONMESH TISSUE REPAIR

DESARDA’S TECHNIQUE FOR INGUINALHERNIA REPAIR”. At Govt.

Kilpauk Medical College Hospital., is a bonafide and genuine research work

carried out by me in the Department of General Surgery, Government Kilpauk

Medical and Hospital, Chennai-10, under the guidance of our Chief

Prof. Dr. P.S.SHANTHI .,MS. DGO, Government Kilpauk Medical College and

Hospital.

This dissertation is submitted to THE TAMILNADU DR. M.G.R.

MEDICAL UNIVERSITY, CHENNAI in partial fulfillment of the University

regulations for the award of M.S degree (General Surgery) Branch I, examination

to be held in MAY 2018.

Date:

Place: Chennai Dr. K.Rasu

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation titled “A COMPARATIVE STUDY

OF LICHTENSTEIN MESH REPAIR VS NONMESH TISSUE REPAIR

DESARDA’S TECHNIQUE FOR INGUINALHERNIA REPAIR” within

General Surgery Department at Govt. Kilpauk Medical College Hospital. is a

bonafide research work done by post graduate in M.S. General Surgery,

Government Kilpauk Medical College & Hospital, Chennai-10 under my direct

guidance and supervision in my satisfaction, in partial fulfilment of the

requirements for the degree of M.S. General Surgery.

Date: Prof.P.S.SHANTHI., M.S. DGO

Place: Chennai Professor of General Surgery,

Govt. Kilpauk Medical College,

Chennai-10

ACKNOWLEDGEMENT

I am most thankful to Prof. P.VASANTHAMANI MD., DGO., MNAMS.,

DCPSY., MBA. Dean, Kilpauk Medical College and Hospital for giving me the

opportunity to conduct this study in the Department of General Surgery,

Government Kilpauk Medical College & Hospital, Chennai-10.

I thank Prof. R.Kannan M.S, Professor and Head of the department of

General Surgery for his relentless care and concern that he has provided me to

bring out this dissertation.

My deepest gratitude to my guide and mentor Prof. P.S. SHANTHI. MS,

DGO., Professor of the Department,, Department of General Surgery, Kilpauk

Medical College, who has inspired me immeasurably during my training as a post

graduate student.

I also acknowledge the invaluable advice and inputs received from

Prof. Dr. S.BALAKRISNAN MS, Dr. DHARMARAJAN, M.S, Dr. KENNY

ROBERT M.S, Dr. SURESH BABU M.S., in shaping up this study.

This study would have not been possible without the support of my fellow

post graduates and interns who have been a source of help in need.

The most important part of any medical research is patients. I owe great deal

of gratitude to each and every one of them.

I would like to thank God for the things he has bestowed upon me.

I would like to thank my parents for making me who I am today and for

supporting me in every deed of mine

I thank each and every person involved in making this manuscript from

inception to publication.

ETHICAL COMMITTEE

PLAGIARISM

ABBREVATION EOA - External Oblique Aponeurosis ASIS - Anterior Superior Iliac Spine CT - Computed Tomogram MRI - Magnetic Resonance Imaging

CONTENTS

SL.NO. TITLE PAGE NO.

1. INTRODUCTION 1

2. AIM 3

3. REVIEW OF LITERATURE 5

4. MATERIALS AND METHOD 55

5. RESULTS 60

6 DISCUSSION 69

7. CONCLUSION 74

8. ANNEXURE 76

BIBLIOGRAPHY 77

PROFORMA 80

CONSENT FORM 84

MASTER CHART 86

1

INTRODUCTION

2

INTRODUCTION

In general surgery department routinely doing surgeries for inguinal

hernia repair, various procedures still accepted for inguinal hernia repair like

bassini’s, shouldice, and other tissue based technique. Now commonly used

technique is Lichtenstein tension free mesh repair. Desarda’s technique is tissue

based technique of hernia repair using an undetached strip of external oblique

aponeorosis to strengthen the posterior wall of the inguinal canal.

Present study deals with the comparison of outcome of the Lichtenstein

repair and Desrada’s repair for inguinal hernia

3

AIM OF THE STUDY

4

AIM OF THE STUDY

The Aim of Study is to find the Effectiveness of Non Mesh Tissue Repair

(Desarda) in compared with mesh repair (lichtensein)

1. Reducing Post-Operative Pain,

2. Recurrence,

3. Complication

4. Duration of Hospital Stay

5. Return To Normal Non Strenuous Activity

5

REVIEW OF LITERATURE

6

REVIEW OF LITERATURE

HISTORY

The history of hernia is the history of Sur-Josef Patinoheliodorus-

surgeon who performed the first hernia operation. Aulus Cornelius Celsus-

first writer to write detailed description of hernia surgery in 50 ad. in 18th

century great anatomist and surgeons described the age of dissection was

done by Paston Cooper, Franz K Henelbach,” Don Antonio De Gimbernat,

Jean Lou Petit' they described detailed anatomy which lead to modern in

hernia repair. Bassini's (1844-1924) described the posterior wall

strengthening of the inguinal wall and high ligation of sac with anatomical

reconstruction. Later his techniques are modified0 therefore he is

rightfully called as father of the modern Herniorrhaphy. Halstead (1852-

1922) developed a Bassini's technique modification. A canadian surgeon

Shouldice (1960) described Overelapping layers with continuous sutures.

Tension free repairs (lichenstein) described strengthening of posterior wall

with mesh with very low recurrence rate. mesh introduced by üsher.

Laparoscopically Ger did first repair, TAPP in 1991 by Arregui and TEP

by Philips, tension free nonmesh tissue repair described by Indian surgeon

Desarda

7

8

9

Inguinal hernias remains an important surgical problem because of there

frequency.Average Life time risk for inguinal hernia is 27% for men, 3% for

women (Primatesta and Goldacre, 1996)1. Annual morbidity rates in various

countries vary from 100 to 300 per 100,000 populations (Bay Nielsen et al,

2001).2 Until 2009 there were no written surgical guidelines for hernia

treatment, when the European hernia society (EHS) published its

recommendations based on analysis of the literature and the results of clinical

trials. In the EHS guidelines, mesh based techniques-the Lichtenstein technique

in particular and endoscopic methods are recommended for treatment of

primary inguinal hernia in adult men (strength of recommendation 1A). In a

departure from this firm opinion presented by the EHS, the Shouldice method

has been acknowledged to be acceptable (Simons et al., 2009)3. Some questions

can be asked considering these facts; is the Shouldice technique the only

nonmesh method that ensures good clinical; results?are any other tissue based

techniques effective in inguinal hernia repair performed correctly? The synthetic

prostheses most often used in the inguinal hernia can create new clinical

problems, such as foreign body sensation in the groin, discomfort, and

abdomimal wall stiffness, which may affect the every day functioning of the

patient (D’Amore et al., 2008)4. Surgical site infections often with clinical

symptoms delayed for years are more frequent after hernia treatment using mesh

(Genc et al., 2010; Scott et al., 2002)5 6

, migration of the mesh from the primary

site of implantation in the abdominal cavity is one of the most dangerous

10

complications (Jeans et al., 2007; Ott et al., 2005)7,8

Intense chronic

inflammatory process typically associated with foreign body reactions around

the mesh may produce Meshoma or Ptumors, the treatment of which becomes a

new surgical challenge (Mcroy 2010).9 Procreation and sexual function are

reportly seriously affected after surgical hernia treatment with mesh (Ott et al.,

2005).8

The observed complication rates and postoperative dysfunction have

influenced many investigations to look for new hernia repair techniques or

modify old methods. An example of such efforts is the Desarda method, which

was presented in 2001 and become a new surgical method for tension free tissue

based inguinal hernia repair (Desarda, 2001a; Desarda 2001b).10,11

Because the

results of our prospective study involving the technique were promising and

comparable to results presented by other authors (Mitura and Romanczuk, 2008;

Szopinski et al., 2005).12,13

HERNIA DEFINITION

Hernia is a general term used to describe a bulge or protrusion of an

organ through the structure or muscle that usually contains it

11

TYPES OF HERNIA

1. Internal hernia

2. External hernia

INTERNAL HERNIA

Protrusion of the gut through the peritoneum, mesentery, or momentum

into compartment of abdominal cavity, the hernia orifice is usually a pre

existing foramen, recess, and fossa but can be caused by surgery, ischemia and

trauma.

EXTERNAL HERNIA (abdominal hernia)

External or abdominal hernia is the bulging of part of the contents of the

abdominal cavity through a weakness in the abdominal wall.

CAUSES OF HERNIA

Basic design weakness

Weakness due to structures entering and leaving abdomen

Developmental failures

Genetic weakness of collagen

Sharp and blunt trauma

Weakness due to ageing and pregnancy

12

Primary neurological and muscle disease

Excessive intra abdominal pressure

COMPOSITION OF HERNIA

Hernia consists of the three parts-

The sac

The coverings of sac

The contents of the sac

Sac

The sac is a diverticulum of peritoneum, consisting of

Mouth

Neck

Body

Fundus

13

Coverings

Coverings are derived from the layers of the abdominal wall through

which the sac passes

14

HERNIA CLASSIFIED DEPEND ON THE SITE

15

INGUINAL HERNIA

Inguinal hernia means protrusion of abdominal contents through the

inguinal canal, its often referred to as a” rupture “by patients, most comment

hernia in men and women but much more common in men.

ANATOMY OF INGUINAL CANAL

The inguinal canal in the adult is an oblique rift in the lower part of the

anterior abdominal wall. It measures approximately 4 cm length.it is located 2-4

cm above the inguinal ligament, between the opening of the external

(superficial) and internal (deep) rings

BOUNDARIES:

Anterior : aponeurosis of the external oblique muscle, more laterally the

internal oblique muscles

Posterior: posterior wall (floor) is formed laterally by the aponeurosis of the

transversus abdominis muscle and the transversalis fascia, 1/4 of the individual

transversalis facscia only. Medially the posterior wall is reinforced by the

internal oblique aponeurosis

Superior: roof of the canal is formed by the arched fibres of the lower edge

(roof) of the internal oblique aponeurosis

16

Inferior : the wall of the canal is formed by the inguinal ligament (poupart’s)

and the lacunar ligament (Gimbernat’s)

Contents: spermatic cord in males, round ligamants in females

17

SPERMATIC CORD

The spermatic cord consists of a matrix of connective tissue continuous

proximally with extraperitoneal connective tissue. Following are the contents

and coverings of spermatic card

Three fasciae:

External spermatic (from external oblique fascia)

Cremastric (from internal oblique muscle and fascia)

Internal spermtic (from transversalis fascia)

Three arteries:

Testicular artery

Cremasteric artery

Deferential artery

Three veins:

Pampiniform plexus and testicular vein

Cremasteric vein

Deferential vein

18

Three nerves:

Genital branch of genitofemoral nerve

Ilioinguinal nerve

Sympathetic nerves (testicular plexus)

Lympatics

LAYERS OF THE ABDOMINAL WALL IN THE INGUINAL REGION

1. Skin

2. Subcutaneous fasciae (camper and scarpa) contain fat (superficial fascia)

3. Innominate fascia (Gallaudet)

4. External oblique aponeurosis, including the inguinal, lacunar and

reflected inguinal ligaments

5. Spermotic cord

6. Transversus abdominis muscle and aponeurosis, internal oblique muscle,

falx inguinalis (Henle) conjoint tendon

7. Anterior lamina of transversalis fascia

8. Posterior lamina of transversalis fascia

9. Preperitoneal connective tissue with fat

10. Peritoneum

19

LAYERS OF THE ABDOMINAL WALL IN THE INGUINAL REGION

20

Scarpa's Fascia

Scarpa's fascia is a homogeneous membranous sheet of areolar tissue that

forms a lamina in the depths of the subcutaneous tissues and usually is most

prominent in the region of the groin. It is loosely connected to the external

oblique muscle, but in the midline it is more intimately adherent to the linea

alba and to the pubic symphysis, and is prolonged onto the dorsum of the penis,

forming the fundi form ligament (suspensory ligament of the clitoris in

females): below and laterally, it blends with the fascia lata of the thigh.

External Oblique Muscle and Aponeurosis

The external oblique muscle is the most superficial of the three flat

musculo aponeuroticlayers that make up the anterolateral wall of the abdomen.

It is directed inferiorly and medially extending from the posterior aspects of the

lower eight ribs to the linea alba, the pubis, and the iliac crest. Medially, the

tendinous fibers pass anterior to the rectus abdominis muscle, forming the

anterior layer of the rectus sheath.

Inguinal Ligament

The inguinal ligament is the lower, thickened portion of the external

oblique aponeurosis suspended between the anterior superior iliac spine and the

pubic tubercle. The fibers of the external oblique aponeurosis that form the

inguinal ligament present arounded surface toward the thigh and a hollow

21

surface toward the inguinal canal functioning as supporting shelf for the

spermatic cord

Lacunar Ligament

First described by Antonio de Gimbernat in 1793, the lacunar ligament is

a triangular extension of the inguinal ligament before its insertion upon the

pubic tubercle. It is inserted at the pecten pubis, and its lateral end meets the

proximal end of the ligament of Cooper. It is considered the medial border of

the femoral canal

External Inguinal Ring

The superficial or external inguinal ring is located above the superior

border of the pubis, immediately lateral to the pubic tubercle. It is a triangular

opening of the aponeurosis of the external oblique, the base being part of the

pubic crest with the margins formed by two crura, medial and lateral. The

medial crus is formed by the aponeurosis of the external oblique itself: the

lateral crus is formed by the inguinal ligament. To be more specific, the medial

crus is attached to the lateral border of the rectus sheath and to the tendon of the

rectus abdominis muscle. The lateral crus is attached to the pubic tubercle

22

Internal Oblique Muscle and Aponeurosis

The internal oblique muscle and aponeurosis represent the middle layer of

the three flat musculo aponeurotic layers of the abdominal wall. The internal

oblique musclearises in part from the thoracolumbar fascia and the iliac crest

splaying obliquely upward, forward, and medially to insert upon the inferior

borders of the lower three or four ribs, the line a alba and the pubis

Transversus Abdominis Muscle and Aponeurosis

The transversus abdominis muscle and aponeurosis are the deepest of the

three flat anterior abdominal muscles layers. These layers arise from the fascia

along the iliac crest, thoracolumbar fascia, iliopsoas fascia, and from the lower

six costal cartilages and ribs. The muscle bundles of the transversus abdominis

course horizontally except the inferior border of the transversus abdominis layer

that forms a curved line, the transversus abdominis arch an important landmark

for the surgeon because it represents the superior border of the direct inguinal

hernia space. The area beneath the arch and the number of aponeurotic fibers

and strength in this lower portion of the transversus abdominis lamina varies,

having a major influence in the development of a direct inguinal hernia.

23

Conjoined Tendon

The conjoined tendon is, by definition, the fusion of lower fibers of the

internal oblique aponeurosis with similar fibers from the aponeurosis of the

transversus abdominis where they insert on the pubic tubercle and superior

ramus of the pubis.

lliopubic Tract

The iliopubic tract, described by Alexander Thomson in 1836, is an

aponeurotic band within the transversus abdominis lamina that bridges across

the external femoral vessels that begin near the anterior superior iliac spine and

extend medially to attach to Cooper's ligament at the pubic tubercle. It forms the

inferior margin of the deep musculo aponeurotic layer made up of the

transversus abdominis muscle and aponeurosis and the transversalis fascia.

Cooper's Ligament

Cooper's ligament or the pectineal ligament is a condensation of the SDB

versalis fascia and periosteum of the superior pubic ramus lateral to the pubic

tubercle. It is usually several millimeters thick and densely adherent to the pubic

ramus, and joins the iliopubic tract and lacunar ligaments at their medial

insertions. Cooper's ligament is considered the posterior margin of the femoral

canal.

24

Internal Inguinal Ring

The deep or internal inguinal ring, formed mainly by aponeurotic fibers

of the transversus abdominis layer, is located halfway between the pubic

tubercle and the anterior superior iliac spine. At the lateral half of the area

between the transversus abdominis arch above and the illopubic tract below, the

fascia transversalis thickens and forms an incomplete ring in the shape of an

inverted "V", with the open end pointing laterally and superiorly (transversalis

fascia crura), that supports the spermatic cord structures as they enter the

inguinal canal. The inferior border is formed by the iliopubic tract. The

transversus abdominis arch along with the superior crus of the transversalis

fasciaforms the superior border of the deep inguinal ring

Myopectineal Orifice of Fruchaud

H. Fruchaud, a French surgeon, described in 1956 an oval-shaped area in

the groinprotected only by the combined lamina of the aponeurosis of the

transversus abdominis and the transversalis fascia where all groin hernias

originate named myopectinealorifice (MPO). The MPO is bordered:

Superiorly by the arching fibers of the internal oblique and transversus

abdominis muscles medially by the lateral border of the rectus muscle

Inferiorly by Cooper's Ligament

Laterally by the iliopsoas muscle

25

HESSELBACH’S TRIANGLE

Boundaries

Lateral (superior) border: inferior (deep) epigastric vessels

Medial border: lateral margins of rectus abdominis muscle

Base (infero latetral): inguinal ligament

26

TYPES OF INGUINAL HERNIA

1. Lateral (oblique, indirect)

2. medial (direct)

3. sliding

By origin

1. Congenital

2. Acquired

Types of hernia by complexity

1. Occult-not detectable clinically, only symptom sever pain

2. Reducible –a swelling which appears and disappears

3. Irreducible-a swelling which cannot be replaced in the abdomen, high

risk of complications

4. Strangulated-painful swelling with vascular compromise, requires urgent

surgery

5. Infarcted-when contents of the hernia have become gangrenous, high

mortality

27

ACCORDING TO EXTENT

1. Bubonocele

Hernia does not come out of the superficial inguinal ring

2. Incomplete hernia

Hernia comes out through the external ring but fails to reach the bottom

of the scrotum

3. Complete hernia

Hernia reaches the bottom of scrotum

ACCORDING TO CONTENTS

1. Enterocele

When Intestine is the content it’s called as enterocele

2. Omentocele (epiplocele)

When omentum as content it’s called omentocele

3. Cystocele

Urinary bladder is content it’s called cytoskeleton

28

CLASSIFICATION

Many surgeons over the past hundred years have attempted to classify

inguinal hernias, including casten, halverson and McVay, zollinger, ponka,

Gilbert and Nyhus.

The European hernia society has recently suggested a simplified system of

Primary or recurrent (P or R)

Lateral, medial or femoral (L, M or F)

Defect size in finger breadths assumed to be 1.5 cm

A primary, indirect, inguinal hernia with a 3 cm defect size would be PL2

29

RARE VARIETIES OF HERNIA

1. Sliding hernia or hernia –en- glissando

In this type of hernia a piece of extraperitoneal bowel, slides down the

outside of hernial sac forming a parts of its wall being covered by the

peritoneum on the hernia aspect only.

Usually,

Right side- caecum

Left side-sigmoid colon

Either side- Urinary bladder

A large globular hernia when descends well into the scrotum this

condition is suspected.

30

2. Richter’s hernia

In this type a portion of the circumference of the bowel becomes

strangulated

31

3. Litter’s hernia

In this type meckel’s diverticula is the content

4. Maydl’s hernia (Hernia –en-w) or retrograde strangulation

In this type two loops of bowels remain in the sac and the connecting

loop remains within the abdomen and becomes strangulated, the loops of hernia

look like W

32

5. Pantaloon hernia (double hernia, saddle hernia, Romberg hernia)

Its contains both direct and indirect inguinal hernia sacs

Clinically present as direct hernia

6. Infantile hernia

In this type processes vaginalis is closed at internal ring and hernia sac

either invaginates processes vaginalis as inverted umbrella or comes behind the

processus vaginalis.

33

7. Amyand’hernia

It is a rare variety, less than 1% of inguinal hernia, here appendix as the

contents of hernia sac

34

THEORIES FOR HERNIA FORMATION

1. Reid's metastatic emphysema theory

due to smoking

2. Cloquet's lipoma theory

due to the pile driver action of fat

3. Fruchaud's theory

Due to large opening in the lower abdomen - inbetween the pubic bone

and conjoint tendon. Divided into two half by inguinal ligament. Through the

upper half part passes the inguinal hernia, while through the lower half part

passes the femoral hernia.

4. Denervation theory

Ilioinguinal nerve injury after appendectomy.

5. Oblique pelvis

Due to high arch of the internal oblique , inefficient shutter mechanism,

prone to inguinal hernia.

35

6. Wide female pelvis

Lower arch of internal oblique muscle has more efficient shutter

mechanism - usually indirect inguinal hernias are uncommon in females. Due to

wider femoral ring - femoral hernias are more common in females

7. Uglavasky theory

Due to Chronic increased Intra abdominal pressure

8. Peacock's theory

Due to defect in the collagen synthesis

9. Walk's theory

weakness of abdominal wall at exit of neurovascular bundle

10. Keith's theory

Degeneration of connective tissue ,especially in the fascia transversalis-

due to stress

11. Dr. Desarda’s theory

a) Transversalis fascia is never gives protection from the herniation process

as believed today or stated in the text books or various research articles.

36

b) Transversalis fascia is very thin like paper and is an extension of the

endo-abdominal fascia

c) Posterior wall of the inguinal canal is not only a single layer wall

composed of the transversalis fascia as believed today but is composed of

two layers. Transversalis fascia is a posterior layer and in front of it is

another layer composed of the aponeurotic extensions from the

Transversus Abdominis Aponeurotic Arch also called as the "Dessidious

part of the Transversus Abdominis Aponeurotic Arch".

These aponeurotic extensions in the posterior wall of the inguinal canal

gives real protection from the herniation process. The inguinal hernia

formation can take place only if these aponeurotic extensions are absent

or deficient. Loss of strength and physiologically a-dynamic nature of the

posterior wall of the inguinal canal due to absent aponeurotic extensions

in the posterior wall and loss of strength of cremasteric fascia and

musculo-aponeurotic structures around the inguinal canal are the real

factors or the cause of hernia formation.

37

Dessidious Part of the Transversus Aponeurotic Arch

38

Complaints

Dull dragging pain referred to the testis - increases on work

If obstructed hernia having symptoms of constipation, vomiting and pain

if strangulated hernia may have severe pain, shock and collapse.

Clinical Findings

Piriform shaped swelling - in the inguinal region

Cough impulse +

Reducibility +

Neck of the hernia is supero-medial to pubic tubercle

Special tests

Deep ring occlusion test

After reducing the swelling deep ring will have been occluded by thumb

Idirect inguinal hernia-swelling does not appear

Direct inguinal hernia-swelling does appear

Finger Invagination test

Indirect hernia- impulse at tip of finger

Direct hernia-impulse at pulp of finger

39

Three finger test-zieman’test

The examiner places his index finger on the deep ring, middle finger on

the external ring, ring finger over the saphenous opening, the patient is asked to

cough, if impulse felt on index finger –indirect hernia

INVESTIGATIONS

Ultrasound

CT scan

MRI scan

Herniogram

Differential Diagnosis:

Males

1. Femoral hernia

2. Direct inguinal

3. Vaginal hydrocele

4. encysted hydrocele of cord

5. Undescended testis

6. Spermatocele

7. Varicocele

8. Diffuse lipoma of cord.

40

Females

9. Femoral hernia

10. Hydrocele of canal of Nuck

TREATMENT FOR HERNIA

Principles of treatment:

1. Restore the disrupted anatomy

2. Repair using fascia / aponeurosis NOT muscle

3. No tension

4. Suture material used should hold until natural support is formed

over it. (i.e. monofilament nylon or polyethylene)

Management

1. Resuscitation - in case of strangulated hernia with gangrene with

shock or with intestinal obstruction.

2. Reduction of hernia - includes taxis, & reduction under anesthesia.

3. Repair - of the defect - may be herniorrhaphy or hernioplasty.

Strangulated hernia -

treat as emergency

treat shock if any. Start IV antibiotics

Incision over the most prominent part of swelling - sac carefully

identified & dissected out. Sac opened.

Aspirate all fluid (highly infectious)

41

Resect any unviable intestine or omentum

EO aponeurosis & external ring divided. Sac opened throughout the

length upto deep ring & a little inside.

Viable contents reduced. Definite repair carried out - any prosthetic

repair is contra-indicated.

- Non - Operative approach - in elderly, unfit / unwilling for surgery.

- Use of truss is advised in such cases- Truss must be applied with

hernia reduced. Must prevent reappearance of the hernia on straining

42

TRUSS

43

Surgery-treatment of chice

Herniotomy

Hernioraphy (Open suture repair)

Bassini

Shouldice

Desarda

Open flat mesh repair

Lichtenstein repair

Open complex mesh repair

Plugs

Hernia systems

Open preperitoneal repair

Stoppa

Laparoscopic repair

TEP (Total Extraperitoneal) approach

TAPP (Trans Abdominal Preperitoneal) approach

44

LICHTENSTEIN REPAIR (Open flat mesh repair)

This is tension free, simple, flat, synthetic mesh repair described by

Lichtenstein in 1980. Synthetic material is polypropylene.

Patient Preparation

This technique can be performed under local, regional, or general

anesthesia. One cited advantage of performing this technique in awake patients

is the opportunity to ask the patient to cough and assess the repair for weakness.

The arms may remain out stretched or can be tucked on the basis of the patient's

body habitus and the surgeon's preference. In routine cases, a urinary catheter is

not necessary. Sufficient bladder decompression is achieved if the patient is

able to urinate immediately prior to the procedure and a consensus is reached

with anesthesia that minimal amounts of intravenous fluids will be administered

intra operatively. The lower abdomen and groin are prepped consistent with the

surgeon's preference. Many surgeons prefer the use of a plastic barrier draped

over the skin to prevent contact of the mesh with the skin. Unless the patient

has a large intra scrotal hernia, the scrotum does not need to be draped into the

operative field. The use of the plastic barrier drape makes it possible to easily

include the umbilicus, the anterior superior iliac spine (ASIS), and the pubic

tubercles into the operative field. A single dose of first generation

cephalosporin is commonly administered for prophylaxis.

45

Procedure:

Under regional anaesthesia patient in supine position, the oblique incision

is essentially made over the distance from the internal to the external ring which

in theory allows for the smallest length of incision needed. The oblique incision

is prepared by marking a line from the ASIS to the pubic tubercle. A 5 to 7 cm

incision is then made parallel 1 cm Cephalad to the previously marked line

which begins medially 2 cm lateral to the pubic tubercle in the anterior

abdominal wall, after opening the layers of abdominal wall such as external

oblique aponeurosis inguinal canal opened. Spermatic cord is dissected,

external spermatic fascia, Cremasteric fascia, internal spermatic fascia opened,

sac identified, presence of lateral or medial is confirmed. The sac of medial

hernia inverted and the transversalis fascia is suture plicated, if the sac is lateral,

opened any contents reduced. The sac is then sutured closed at its neck and

excess sac removed. Medial defect is closed, a piece of mesh, measuring 8x15

cm is placed over the posterior wall, behind the spermatic cord at he deep

inguinal ring.loose sutures hold the mesh to the inguianal ligament and conjoint

tendon, external oblique closed with 2 o vicryl than subcutaneous and skin are

closed.

46

POSTOPERATIVE MANAGEMENT

An ice pack is used for 24 hours on the wound to minimize swelling.

Male patients should wear scrotal support for at least a weak. This reduces

tension on the testicle and increases comfort in the post oparative period.

Patients are given oral narcotic pain medication and non-steroidal anti-

inflammatory agents for pain. Most patients can return to work depending on

the physical requirements in 1 to 2 weeks, but there is a wide variation on the

basis of patient motivation and the extent of physical activity required. Patients

are advised to avoid truly strenuous lifting for 6 weeks postoperatively

47

Mesh

Lichtenstein repair

48

LIMITATIONS OF MESH

Presence of infection

Expensive

COMPLICATIONS

1) recurrence

2) chronic groin pain

3) sepsis & sinuses

4) testicular damage

5) migration

6) perforation

7) rejection

DESARDA REPAIR

Skin and fascia are incised through a regular oblique inguinal incision to

expose the external oblique aponeurosis. The thin, filmy fascial layer covering it

is kept undisturbed as far as possible. The thinned out portion is usually seen at

the top of the hernia swelling, extending and fanning out to the lower crux of

the superficial ring.

The external oblique is cut in line with the upper crux of the superficial

ring, which leaves the thinned out portion in the lower leaf so a good strip can

be taken from the upper leaf. The external oblique, which is thinned out as a

49

result of aging or long standing large hernias, can also be used for repair if it is

able to hold the sutures. The Cremasteric muscle is incised for the Herniotomy

and the spermatic cord together with the Cremasteric muscle is separated from

the inguinal floor. The sac is excised in all cases except in direct hernias where

it is inverted. The medial leaf of the external oblique Aponeurosis is sutured

with the inguinal ligament from the pubic tubercle to the abdominal ring using

PDSII no.1 (Monofilament Polydioxanone Violet) continuous sutures. The first

two sutures are taken in the anterior rectus sheath where it joins the external

oblique aponeurosis. The last suture is taken so as to narrow the abdominal ring

sufficiently without constricting the spermatic cord (In fact, here we are creating

a new internal ring. Each suture is passed first through the inguinal ligament,

then the transversalis fascia, and then the external oblique. The index finger of

the left hand is used to protect the femoral vessels and retract the cord structures

laterally while taking lateral sutures.

A splitting incision is made in this sutured medial leaf, partially

separating a strip OF 1-2 CMS. WIDTH but NEVER more than 2 cms. This

splitting incision is extended medially up to the pubic symphisis and laterally 1–

2 cms beyond the abdominal ring. The medial insertion and lateral continuation

of this strip is kept intact. A strip of the external oblique, is now available, the

lower border of which is already sutured to the inguinal ligament. The upper

free border of the strip is now sutured to the internal oblique or conjoined

muscle lying close to it with PDSII no.1 (Monofilament Polydioxanone violet)

50

continuous sutures throughout its length The aponeurotic portion of the internal

oblique muscle is used for suturing to this strip wherever and whenever

possible; otherwise, it is not a must for the success of the operation. This will

result in the strip of the external oblique being placed behind the cord to form a

new posterior wall of the inguinal canal.

At this stage the patient is asked to cough and the increased tension on the

strip exerted by the external oblique to support the weakened internal oblique

and transversus abdominis is clearly visible. The increased tension exerted by

the external oblique muscle is the essence of this operation. The spermatic cord

is placed in the inguinal canal and the lateral leaf of the external oblique is

sutured to the newly formed medial leaf of the external oblique in front of the

cord, as usual, again using PDSII no.1 (Monofilament Polydioxanone violet)

continuous sutures. Undermining of the newly formed medial leaf on both of its

surfaces facilitate its approximation to the lateral leaf. The first stitch is taken

between the lateral corner of the splitting incision and lateral leaf of the external

oblique. This is followed by closure of the superficial fascia and the skin as

usual.

51

Strip of the External Oblique – Lower Border Sutured to the Inguinal

Ligament

Strip of the External Oblique – Upper Border Sutured to the Internal

Oblique or Conjoined Muscle

52

External Oblique Closure – New Formed

53

Mechanism of action:

Contractions of the abdominal wall muscles pull this strip upwards and

laterally against the fixed structures like inguinal ligament and pubic symphisis,

creating tension above and laterally and turning the strip into a shield to prevent

any herniation. This additional strength given by the external oblique muscle to

the weakened muscle arch to create tension in the strip and prevent re-herniation

is the essence of this operation. The shielding action of the strip of EOA can be

elegantly demonstrated on the operating table by asking the patient to cough.

Second important factor that prevents hernia formation in the normal

individuals is anterior-posterior compression of the inguinal canal caused by the

external oblique aponeurosis compressing against the posterior wall. This

compression is lost if the posterior wall is weak and flabby due to absent

aponeurotic extension cover. The strip of EOA sutured in this operation gives

the aponeurotic cover to the posterior wall transversalis fascia again and restores

this anterior-posterior compression effect during the raised intra-abdominal

pressures. The contraction of the external oblique muscle pulls anterior

aponeurosis and the posterior placed strip also, naturally compressing the

inguinal canal.

54

55

MATERIALS AND METHODS

56

MATERIALS AND METHODS

Study Site

Department of General Surgery, Kilpauk Medical College and Govt.

Royapettah Hospital, Chennai.

Collaborating Departments

Department of Anaesthesiology

Department of Radiology

Department of General Medicine

Department of Medical Biochemistry

Study Period

February 2017 to September 2017

Materials : All Patients Having Inguinal Hernia Diagnosed

Clinically and by Radiological Examination were

Included in the Study

Methodology : Over A Period of Eight Months 50 Patients Aged

Between 21 & 60 Years Treated for Inguinal Hernia

were Included in this Prospective Randomised

Study.

Patients were Randomly Divided into Two Equal

Groups.

57

Group I (Control Group) Were Subjected to

Lichenstein Tension Free Mesh Repair

Group II (Study Group) were Subjected to Desarda

Non Mesh Tissue Repair Patients Above 50 Years of

Age and any Patients Associated with Recurrent

Inguinal Hernia and Patients with Obstruction Ir-

reducible Inguinal Hernia were not Included in our

Study.

Type of Study : Prospective study

Sample Size : 50

Inclusion Criteria:

1. Adult patients above the age of 21 years.

2. Patient With Clinically Demonstrable Inguinal Hernia Were Included In

Study

Exclusion Criteria:

1. Patients over 60 years of age.

2. Patients Associated with Recurrent Inguinal Hernia

3. Patients with Obstruction Ir-reducible Inguinal Hernia

58

Type of analysis: Clinical data analysis

Data Collection:

The data of each patient was collected in a specially designed proforma

which is enclosed.

Statistical Analysis

Descriptive statistics was done for all data and suitable statistical tests of

comparison were done. Continuous variables were analysed with the Unpaired

test and categorical variables were analysed with Fisher Exact Test. Statistical

significance was taken as P < 0.05. The data was analysed using SPSS Version

16. Microsoft Excel 2010.was used to generate charts

Ethical Considerations

The following ethical guidelines were put into place for the research period:

The dignity and wellbeing of students was protected at all times.

The research data remained confidential throughout the study and the

researcher obtained the students’ permission to use their real names in the

research report.

Research protocol was presented in Institutional Ethical review Board

and due permission was obtained to undertake the study

59

Conflict of Interest

Study is self-sponsored with support from institution. There is no

commercial or conflict of interest

60

RESULTS

61

RESULTS

1. AGE DISTRIBUTION

AGE (YEARS) LICHTENSTEIN (N=25) DESRADA (N=25)

21-40 10 9

41-60 15 16

There is no significance difference regarding age

Figure 1. AGE DISTRIBUTION

AGE

21-40 YEARS

41-60 YEARS

62

2. SEX

SEX LICHENSTEIN (N=25) DESARDA (N=25)

MALE 25 25

FEMALE 0 0

There is no difference regarding sex

Figure 1. SEX

MALE

LICHTENSTEIN

DEESARDA

63

3. LOCATION

LOCATION LICHTENSTEIN (N=25) DESARDA (N=25)

RIGHT 14 13

LEFT 11 12

BILATERAL 0 0

There is no difference regarding location of hernia

Figure. 2 LOCATION OF HERNIA

LICHTENSTEIN

DESRDA

64

4. DURATION OF HOSPITAL STAY

DURATION LICHTENSTEIN

(N=25)

DESARDA (N=25)

SHORT (<3 DAYS) 18 22

LONG (>3 DAYS) 7 3

Mean hospital stay for Desarda’s group was less than 3 days, for

Lichtenstein group was more than 3 days (p value <0.0001)

Figure 4. DURATION OF HOSPITAL STAY

SHORT DURATION< 3DAYS

LONG DURATION>3 DAYS

65

5. PAIN

Analysis of pain score according to visual analogue score,

66

PAIN (MILD TO

MODERATE)

LICHTENSTEIN (N=25) DESARDA (25)

FIRST POD 23 19

THIRD POD 24 16

FIFTH POD 21 13

Mild to moderate on 1st,3

rd,5

th post operative days was significantly

less in Desarda’s group as compare to Lichtenstein group(P value <0.0001).

Figure 5. PAIN

LICHTENSTEIN

DESARDA

67

6. COMPLICATIONS

COMPLICATIONS LICHTENSTEIN

(N=25) DESARDA (N=25)

SEROMA 4 1

WOUND INFECTION 3 1

HEMATOMA 4 1

ORCHITIS 0 0

TESTICULAR ATROPHY 0 0

RECURRANCE 0 0

There is no recurrence between both groups, complications are more for

Lichtenstein group then Desarda group (p value <0.0034).

There were no case of chronic groin pain lasting more than 3 month in

either of the group.

Figure 6. COMPLICATIONS

LICTENSTEIN

DESARDA

68

7. RETURN TO NORMAL NON STERNOUS ACTIVITY

RETURN TO

NORMAL NON

STERNOUS WORK

LICHTENSTEIN

(N=25)

DESARDA (N=25)

1-7 DAYS 3 7

8-15 DAYS 12 21

16-30 DAYS 20 24

Return to normal nonsternous Activity After 7-15 days in Desarda group

was 84 % while only 48% of patient in lichtenstein repair.(p value <0.0001).

Figure 7. RETURN TO NORMAL NONSTERNOUS ACTIVITY

LICHTENSTEIN

DESARDA

69

DISCUSSION

70

DISCUSSION

Lichtenstein Mesh repair is now widely used, and is often referred to

as the gold standard despite a relatively paucity of clinical trial comparing mesh

with suture repair. Cost of surgery 14

and post-operative morbidity affecting the

quality of life are important consideration in the inguinal hernia surgery. There

are no clear scientific evidence to improve to prove that the mesh prosthesis

repair is superior to non-prosthesis repair in this respect Porrero JL. El Cambio

et al.15

There are advantages and disadvantages associated with all types of

open inguinal hernia surgery. Existing non prosthesis repair (Bassini/Shuldice)

is blamed for causing tissue tension and mesh repair is blamed for causing

complication of foreign body. Desarda’s suture an undetached strip of the

external oblique aponeurosis between the muscle arch and the inguinal ligament

to give a strong and physiologically dynamic postriorwall16

.The posterior wall

of the inguinal canal was weak and without dynamic movement in all patients.

Strong aponeurotic extensions were absent in the posterior wall. The muscle

arch movement was lost or diminished in all patients. The movement of the

muscle arch improved after it was sutured to the upper border of a strip of the

external oblique aponeurosis (EOA). The newly formed posterior wall was kept

physiologically dynamic by the additional muscle strength provided by external

oblique muscle to the weakened muscles of the muscle arch. A physiologically

71

dynamic and strong posterior inguinal wall, and the shielding and compression

action of the muscles and aponeurosis around the inguinal canal are important

factors that prevent hernia formation or hernia recurrence after repair. In

addition, the squeezing and plugging action of the cremasteric muscle and

binding effect of the strong cremasteric fascia, also play an important role in the

prevention of hernia MP Desarda et al.

17 Desarda’s result in a tension free repair

without the use of any foreign body, being simple to perform.

For inguinal hernia repair, different studies have tried to give an answer

as to which of the existing technique is better 18

.THE EU HERNIA

COLLABRATION made a systemic revision of the randomized prospective

studies and analysis of the result of different studies. The use of synthetic mesh

substantially reduces the risk of hernia recurrence irrespective of placement

method. Mesh repair appears to reduce the chance of persisting pain rather than

increase it Mcgillicuddy JE et al.19

No patient had severe pain postoperatively and nearly all patients (n =

396) were free of pain and discomfort after the second postoperative day. 340

patients (85%) were discharged by the 4th postoperative day, and most returned

to normal activities within 2 weeks. There was 1 early Haematocele, and 1

recurrence at 2 years Desarda MP et al10

.In this study Return to normal

nonsternous Activity After 7-15 days in Desarda group was 84 % while only

48% of patient in lichtenstein repair.(p value <0.0001).

72

After Desarda repair there was less intensive postoperative pain, rated in

VAS scale at 3.3 in first day after the surgery, 2.1 in second day and 1.5 in third

one, respectively in group II rated at 3.8, 2.7 and 1.6. Patients after Desarda

repair were discharged from hospital on fourth day after the surgery, in group II

on fifth postoperative day (p < 0.05). One week after the hemia repair patients

in both groups equally classified the intensity of the pain (VAS 1.2). Six months

after the hospitalization the effect of performed surgery was described as good

or very good. Only one patient in group I was unsatisfied with the surgery

results. There was minor intensity of the pain at this point--similar in both

groups (I--0.8, II--1.1). Full activity was achieved by 46 patents in group I and

45 in group II. There was no hernia recurrence among the patients six months

after the surgery Mitura K, Romanczuk M et al.12

In This study mild to

moderate pain only noticed mild to moderate on 1st, 3

rd, 5

th post-operative days

was significantly less in desarda’s group as compare to Lichtenstein group(P

value <0.0001).

A total of 208 male patients were randomly assigned to the D or L group

(105 vs. 103, respectively). The primary outcomes measured were recurrence

and chronic pain. Additionally, early and late complications, foreign body

sensation, and return to everyday activity were examined in hospital and at 7,

30 days, and 6, 12, 24, and 36 months after surgery. During the follow-up, two

recurrences were observed in each group (p = 1.000). Chronic pain was

73

experienced by 4.8 and 2.9% of patients from groups D and L, respectively

(p = 0.464). Foreign body sensation and return to activity were not different

between the groups. There was significantly less seroma production in the D

group (p = 0.004) Szopinski J, Kapala A, Prywinski S, et al.13

In This study no

one documented chronic pain after both groups, significantly seroma less in

desarda group (4%) compared to Lichtenstein group(16%), p value <0.0034)

The external oblique muscle technique satisfies all criteria of modern

hernia surgery. Desarda’s technique is simple and easy to do. It does not require

risky or complicated dissection. There is no tension in suture line .It does not

require any foreign material and does not use weak muscle or fascia

transversalis for repair. It does not use mesh prosthesis so it is more economical

and also avoid morbidity associated with foreign body like rejection, infection,

chronic groin pain. Szopinski et al.,20

stated in their Randomized controlled trial

that the Desarda’s technique has the potential to enlarge the number of tissue

based method available to treat groin hernias. The most evident indication for

use financial constraints or if a patient disagree with the use of mesh..

74

CONCLUSION

75

CONCLUSION

The study is designed to compare the outcome of Lichtenstein tension

free mesh repair and Desarda’s repair. Though it requires studying large number

of patients and a longer follow up, based on the results of our study following

conclusion drawn.

1. The Lichtenstein repair and Desarda procedures of primary inguinal

hernia repair do not differ in the means of procedure, complexity

2. local complications an pain intensity is higher in Lichtenstein repair

compared to Desarda’s repair

3. The time taken for return to normal nonsternous activity is significantly

higher for Lichtenstein group compared to Desarda’s repair. The patients

are satisfied with the Lichtenstein repair and Desarda’s repair with

surgery outcome.

4. There is no recurrence of hernia seen in both groups during follow up

period. Desarda’s technique is based on the physiological principles. This

operation is simple to perform, does not require foreign body like mesh or

complicated dissection of the inguinal floor as in bassini and shuoldice

5. Desarda’s technique is cost effective when compared with Lichtenstein

method, so early can do in rural areas

6. The mean hospital stay is low for Desarda’s repair compared to

Lichtenstein repair

76

ANNEXURE

77

BIBLIOGRAPHY

1. Primatesta P, Goldacre MJ. Inguinal Hernia Repair: Incidence of Elective

And Emergency Surgery, Readmission And Mortality. Int J Epidemiol.

1996; 25:835–839.

2. Bay-Nielsen M, Kehlet H, Strand L, Et Al. Quality Assessment Of 26,304

Herniorrhaphies In Denmark: A Prospective Nationwide Study. Lancet.

2001;358:1124–1128.

3. Simons MP, Aufenacker T, Bay-Nielsen M, Et Al. European Hernia

Society Guidelines On The Treatment Of Inguinal Hernia In Adult

Patients. Hernia. 2009;13:343–403.

4. D’Amore L, Gossetti F, Vermeil V, Et Al. Long-Term Discomfort After

Plug And Patch Hernioplasty. Hernia. 2008;12:445–446.

5. Genc V, Ensari C, Ergul Z, Et Al. A Very Late-Onset Deep Infection

After Prosthetic Inguinal Hernia Repair. Chirurgia (Bucur)

2010;105:555–557

6. Scott NW, Mccormack K, Graham P, Et Al. Open Mesh Versus Non-

Mesh For Repair Of Femoral And Inguinal Hernia. Cochrane Database

Syst Rev, 2002.

7. Jeans S, Williams GL, Stephenson BM. Migration After Open Mesh Plug

Inguinal Hernioplasty: A Review Of The Literature. Am Surg.

2007;73:207–209.

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8. Ott V, Groebli Y, Schneider R. Late Intestinal Fistula Formation After

Incisional Hernia Using Intraperitoneal Mesh. Hernia. 2005;9:103–104.

[9] Mcroy LL. Plugoma And The Prolene Hernia System. J Am Coll

Surg. 2010;212:424

9. Desarda MP. Inguinal Herniorrhaphy With An Undetached Strip Of

External Oblique Aponeurosis: A New Approach Used In 400 Patients.

Eur J Surg. 2001a;167:443–448.

10. Desarda MP. New Method Of Inguinal Hernia Repair: A New Solution.

ANZ J Surg. 2001b;71:241–244.

11. Mitura K, Romanczuk M. Comparison Between Two Methods Of

Inguinal Hernia Surgery—Lichtenstein And Desarda. Pol Merkur

Lekarski. 2008;24:392–395.

12. Szopinski J, Kapala A, Prywinski S, Et Al. Desarda Technique For

Inguinal Hernia Treatment: First Polish Experiences. Pol Przegl Chir.

2005;77:159–168

13. Costos Hospitalarios. Comunicación Personal. Departamento Económico.

Hospital Enriquecabrera. Enero. 2005.

14. Porrero JL. El Cambio De La Cirugía De La Hernia En La Última

Década. En:

15. Celdran A, De La Pinta JC, Editores. Fundamentos De La Hernioplastia

Sin Tensión. Madrid: Fundación Jiménez Díaz: 1999. P. 9- 11.

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16. MP Desarda. Surgical Physiology Of Inguinal Hernia Repair-A Study Of

200 Cases. BMC Surgery 2003; 3:1-9. [18] Simons MP, Kifignen J, Van

Geldere D, Hoitsmahfw, Obertop H. Role Of The Shouldice Technique In

Inguinal Hernia Repair: A Systematic Review Of Controlled Trials And

Meta-Analysis. Br J Surg 1996; 83:734-8.

17. Mcgillicuddy JE. Prospective Randomized Comparison Of The Shouldice

And Lichtenstein

18. Hernia Repair Procedures. Arch Surg 1998; 133: 974-8. [21] EU Hernia

Trialist Collaboration. Mesh Compared With Non-Mesh Methods Of

Open Groin

19. Hernia Repair: Systematic Review Of Randomized Controlled Trials. Br

J Surg 2000; 87: 854-9.

20. Jacek Szopinski, Stanislaw Dabrowiecki, Stanislaw Pierscinski,

Marekjackowski,

21. Maciejjaworski, Zbigniewszuflet. Desarda Versus Lichtenstein

Technique For Primary

22. Inguinal Hernia Treatment: 3-Year Results Of A Randomized Clinical

Trial. World J Surg. 2012 May;36(5):984-92. Doi: 10.1007/S00268-012-

1508

23. Bailey and love’s 26 edition, chapter 60,948-961

24. A surgical anatomy-skandalakis (2004),chapter 9,]

80

PROFORMA

NAME: AGE: SEX:

ADDRESS UNIT:

IP NO:

OCCUPATION:

DOA: DOS: DOD:

PRESENTING COMPLAINTS:

DURATION OF COMPLAINTS:

ANY SIGNIFICANT PAST/PRESENT HISTORY:

ANY SIGNIFICANT COMORBIDITIES:

81

PHYSICAL EXAMINATION:

Level of consciousness

Orientation

Hydration status

Anemia

Jaundice

Vitals

CVS/RS

Abdomen

CNS

P/R:

P/V:

External genitalia

INVESTIGATIONS:

BLOOD

Complete hemogram

Renal Function tests

Serum electrolytes

XRAY ABDOMEN ERECT

USG ABDOMEN

82

SURGICAL MANAGEMENT AND OPERATIVE FINDINGS

COMPLICATIONS DURING IMMEDIATE POSTOPERATIVE PERIOD UPTO

30 DAYS

POSTOPERATIVE ASSESSMENT

Patient Name : Age : Sex:M/F

IP No.:

LICHENSTIN

REPAIR

DESARDA

REPAIR

P

VALUE

AGE

21-40 YEARS

41-60 YEARS

SEX

MALE

FEMALE

LOCATION

RIGHT

LEFT

BILATERAL

HOSPITAL STAY

SHORT DURATION

< 3 DAYS

LONG

DURATION>3DAYS

83

PAIN(MILD

TOMODERATE)

1 POD

3POD

5POD

POSTOPERATIVE

COMPLICATIONS

SEROMA

WOUND

INFECTION

HEMATOMA

ORCHITIS

TESTICULAR

ATROPHY

RECURRANCE

RETURN TO

NORMAL NON

STERNOUS WORK

1-7 DAYS

8-15 DAYS

16-30 DAYS

3.Comments :

84

“A COMPARATIVE STUDY OF

LICHTENSTEIN MESH REPAIR VS NONMESH TISSUE REPAIR

DESARDA’S TECHNIQUE FOR INGUINAL HERNIA REPAIR

” Department of General Surgery, GRH, KMCH.

:

:

:

.

.

.

,

.

,

.

.

85

.

:

:

:

:

:

86

MASTER CHART

S.

NO

NA

ME

AG

E

SEX

IPN

O

LIC

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NST

EIN

DES

AR

DA

SID

E

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SPIT

ALS

TAY

OR

CH

ITIS

SER

OM

A

HEM

AT

OM

A

INFE

CTI

ON

TEST

ICU

LAR

ATR

OP

HY

REC

UR

RA

NC

E

1 srinivasan 26 m 86654 +

R <3DAYS 0

0 2 chandran 60 m 87769 +

L <3DAYS 0

+

0 0

3 jegadeesh 55 m 88441 +

R <3DAYS 0

0 0

4 sakthivel 30 m 88765

+ R >3DAYS 0

0 0

5 raji 52 m 89062 +

L > 3DAYS 0

+ 0 0

6 suriya 38 m 89509

+ L <3DAYS 0

0 0

7 raji 42 m 90327

+ R >3DAYS 0

0 0

8 ganesan 58 m 90321 +

R <3DAYS 0

0 0

9 perumal 40 m 90794 +

R <3DAYS 0

0 0

10 mani 60 m 91642

+ L >3DAYS 0 +

0 0

11 balakrishnan 51 m 92822

+ L <3DAYS 0

0 0

12 deva 22 m 93501 +

L <3DAYS 0

0 0

13 ramachandran 38 m 94047

+ L <3DAYS 0

0 0

14 raji 42 m 94655

+ L >3DAYS 0

0 0

15 sundaram 55 m 94696

+ L <3DAYS 0

0 0

16 aslam basa 55 m 95810

+ R <3DAYS 0

0 0

17 duraisamy 60 m 96396

+ R <3DAYS 0

+

0 0

18 karunakaran 58 m 97159

+ L <3DAYS 0

0 0

19 aurumugam 35 m 97985 +

L <3DAYS 0

0 0

20 jeyavel 25 m 98162 +

L <3DAYS 0

0 0

21 sithan 50 m 97959

+ R <3DAYS 0

0 0

22 sheshadri 58 m 98567

+ L <3DAYS 0

0 0

23 muniyandi 55 m 99403

+ R <3DAYS 0

+ 0 0

24 venkatapathy 58

99569

+ L <3DAYS 0

0 0

25 muralikrishna 34 m 98929

+ L <3DAYS 0

0 0

26 duraisamy 60 m 99832 +

R > 3DAYS 0

+

0 0

27 mubarak 24 m 99841

+ R <3DAYS 0

0 0

28 sathish 24 m 100678 +

L <3DAYS 0

0 0

29 dhatchayani 37 m 100765

+ R <3DAYS 0

0 0

30 chandran 37 m 100765

+ R <3DAYS 0

0 0

31 boopalan 36 m 101633 +

L <3DAYS 0

0 0

32 parthiban 62 m 101311

+ R <3DAYS 0

0 0

33 dhanush 25 m 102304

+ R <3DAYS 0

0 0

87

34 hariprasad 38 m 102981 +

R <3DAYS 0 +

0 0

35 rakesh 22 m 103629

+ L <3DAYS 0

0 0

36 krishnan 46 m 104283 +

R <3DAYS 0

0 0

37 sandeep 57 m 105135

+ R <3DAYS 0

0 0

38 ashokkumar 40 m 105087 +

L <3DAYS 0

0 0

39 mohan 48 m 105076

+ L <3DAYS 0

0 0

40 kannan 37 m 105904 +

R <3DAYS 0

0 0

41 ravi 54 m 105799

+ R <3DAYS 0

0 0

42 gopalan 59 m 107215 +

R <3DAYS 0

0 0

43 subramani 60 m 107198 +

L > 3DAYS 0 +

0 0

44 jhon 55 m 107943 +

R <3DAYS 0

0 0

45 muthusamy 42 m 108467 +

R <3DAYS 0 + +

0 0

46 mahalingam 51 m 107848 +

L > 3DAYS 0

0 0

47 saroja 59 m 108895 +

L > 3DAYS 0 +

+ 0 0

48 munusamy 60 m 108875 +

R <3DAYS 0

0 0

49 ayyanar 46 m 108919 +

R > 3DAYS 0

0 0

50 vijayakumar 50 m 108925 +

R > 3DAYS 0

+ + 0 0